Outcomes of early vs delayed medial malleolar fixation in the treatment of open ankle fractures

OBJECTIVE: To investigate outcomes after early versus delayed fixation of clean open ankle fractures involving the medial malleolus. METHODS: Design: Retrospective review. SETTING: Single-center academic Level I trauma center. PATIENT SELECTION CRITERIA: Patients undergoing open reduction and internal fixation from November 2016 to July 2024 for an open ankle fracture involving the medial malleolus (AO/OTA A2-C3). OUTCOME MEASURES AND COMPARISONS: Infection rate, length of stay, number of operations, and return to the operating room were compared between early and delayed fixation groups. RESULTS: The early fixation group consisted of 55 patients (67% female; mean age 55.8 ± 21.1 years), while the delayed fixation group consisted of 44 patients (68% female; mean age 57.5 ± 15.9 years). Infection rates were 22% in the early group and 9% in the delayed group (p=0.09). Early, compared to delayed, fixation was associated with a shorter length of stay (7.8 vs. 12.8 days; p=0.0004), lower external fixation rate (11% vs 82%) and fewer operations (1.3 vs. 2.4; p<0.0001). Wound care was initiated more frequently in the early fixation group (56% vs 27%; p=0.0037). However, there were no statistically significant differences in union rates, antibiotic use, time to full weight bearing, pain scores, or symptomatic nonunion (P>0.05). A post hoc analysis excluding isolated medial malleolus fractures demonstrated a higher infection rate in the early fixation cohort (22% vs 7%; p=0.0487). CONCLUSION: Early fixation was associated with a higher observed infection rate, particularly in bimalleolar and trimalleolar fractures, although this difference did not reach statistical significance in the overall cohort. Early fixation may be appropriate in select cases to reduce hospital resource utilization. However, surgeons should use caution when considering early fixation of higher energy injuries such as open bimalleolar and trimalleolar ankle fractures. LEVEL OF EVIDENCE: Therapeutic Level III.